Kidney transplantation in children involves many unique aspects. Surgical techniques are different in small children. Routine childhood immunizations may not be complete before transplantation. Growth is suboptimal in chronic renal failure, though it is partially recoverable with growth hormones and renal transplantation. Infections and posttransplant lymphoproliferative disorders are proportionately larger concerns in children. Grafting and patient survival have improved dramatically in recent decades.
Keywords:children, growth, immunizations, kidney, pediatrics, posttransplant lymphoproliferative disorders, transplant
Role of Transplantation, 661
Incidence and Frequency of Pediatric Renal Transplantation, 662
Etiology of End-Stage Renal Disease in Children, 662
Indications for Renal Transplantation in Children, 662
Pretransplant Preparation, 663
The Transplantation Procedure, 664
Technical Issues in Transplantation, 664
Evaluation of Graft Dysfunction, 665
Immunosuppression Strategies, 666
Allograft Dysfunction, 667
Hyperacute Rejection, 667
Acute Rejection, 667
Chronic Allograft Dysfunction, 668
Recurrent Kidney Disease, 669
Graft Survival, 670
Growth After Transplantation, 671
Complications of Pediatric Renal Transplantation, 672
Adherence to Chronic Immunosuppression Treatment, 672
Posttransplant Lymphoproliferative Disorder and Malignancy, 672
Other Infections, 673
Posttransplantation Diabetes Mellitus, 675
Long-Term Outcomes of Pediatric Renal Transplantation, 675
Role of Transplantation
Chronic dialysis and renal transplantation are both effective treatments for end-stage renal disease (ESRD). The majority of adults with ESRD are receiving dialysis rather than undergoing renal transplantation, although the number seeking renal transplantation continues to rise. Renal transplantation was recognized as the better form of treatment for children with ESRD many decades ago, and it is known to provide a survival benefit for this population. Both peritoneal dialysis and hemodialysis are not optimal for catch-up growth after the deceleration that occurs in ESRD. Data from the dialysis component of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry, now over 30 years, and from 6842 patients showed that children were significantly behind their peers in somatic linear height at dialysis initiation and did not show much catch-up growth on dialysis without growth hormone therapy. Fluid and dietary restrictions are many; appetite is also generally worse on dialysis than with a transplant. In addition, children do not tolerate being dependent on any modality, and maintenance dialysis induces loss of self-esteem and emotional maladjustment. Also, ESRD of childhood is associated with an impaired cognitive and educational attainment in adulthood. Long duration of dialysis may enhance intellectual impairment, which may not be reversible after renal transplantation. In contrast, the mobility and freedom from dietary restrictions afforded by a functioning renal transplant enable children to live nearly normal lives. Although renal transplantation has not lived up to the promise of normal growth for all children, dramatic short-term improvements in height can be seen in many, and final adult height is improving after transplantation. Most importantly, successful transplantation permits the child to attend school and to develop normally. School function testing improves dramatically after transplantation. Importantly, young children now have the best long-term outcomes of all ages of transplant recipients, verifying the utility of transplantation in this age group. For all of these reasons, successful renal transplantation remains the primary goal of programs that care for children with ESRD. Pediatric recipients of kidney transplants have the highest percentages of living donors (LDs), and they receive preference on the deceased donor (DD) transplant waiting list, leading to relatively short waiting times. Thus pediatric patients with ESRD should not have substantial delays in undergoing renal transplantation after developing ESRD.
Incidence and Frequency of Pediatric Renal Transplantation
In 2016 about 19,000 kidney transplants were performed in the United States, and about 700 of these were in children younger than 18 years. In most years, pediatric patients comprise <5% of all transplant recipients. Although the number of pediatric transplants performed each year has generally varied by no more than 10%, the donor origin has undergone substantial changes. Living kidney donation is generally more prominent in children due to parental motivation to donate. With policies that increased availability to deceased donors for children, living donations fell. In 2016 living donation accounted for 39% of all kidney transplants in the United States, but for 65% of kidney transplants to children. Most of these are living-related, but similar to the adult population, increasing percentages of living-unrelated or paired-exchange donors are being reported.
In the 1980s there was a tendency to preferentially place kidneys recovered from infants into infant recipients (size matching), with high thrombosis rates and disastrous consequences for patient and graft survival. As a result of widespread dissemination of these data, there has been a marked change in practice. The majority of DD kidneys for children are now recovered from adult donors. This change in allocation of kidneys from young donors led to improvement in graft survival. Many programs reserve grafts from very young donors for en bloc transplantation into older recipients.
Etiology of End-Stage Renal Disease in Children
ESRD in children is generally due to congenital or inherited diseases. In reviewing 11,603 transplants in the NAPRTCS database, the most common congenital diagnoses found are aplastic/hypoplastic/dysplastic kidneys and obstructive uropathy, with each representing about 15% of the patients ( Table 43.1 ). Among glomerular disorders, focal segmental glomerulosclerosis (FSGS) is the most common at 11%. The primary diagnosis also varies with the race of the recipient. Caucasian children account for 59% of all recipients; however, Caucasian children account for less than 50% of the children transplanted for FSGS. Table 43.1 shows the primary diagnoses by gender and race of 10,632 children who received a transplant as recorded by NAPRTCS since 1987 and the percentage of biopsy-proven diagnoses. It is important to observe that the biopsy confirmation of the primary diagnosis was made in 94% of FSGS, in 87% of systemic immunological diseases, and in 90% of congenital nephrotic syndrome patients. The information regarding primary diagnosis is critical in predicting graft survival and recurrence of the original disease, as discussed later.
|Age at Transplantation|
|0–1 yr |
|2–5 yr |
|6–12 yr |
|13–17 yr |
|≥18 yr (percent)||Total|
Indications for Renal Transplantation in Children
There has been a substantial change in long-term renal allograft outcome for children across the world during the past three decades. Previously, young children were thought to have poor short- and long-term graft survival related to several factors, most prominently a proposed heightened immune response, especially in infants. The most recent comprehensive registry reviews have clearly demonstrated a dramatic reversal in outcomes with marked improvements in patient and kidney graft survival for infants and young children. Indeed, several analyses have identified these very young recipients as now having the best long-term survivals of all age groups. Thus children of all ages are excellent transplant candidates. Therefore by the time that the child has reached chronic kidney disease (CKD) stage 4 to 5, planning for kidney transplantation and pretransplant preparation should have begun. There are very few contraindications to kidney transplantation in children. Perhaps the only two are the presence of another otherwise-fatal condition with a short projected survival, such as metastatic Wilms’ tumor and severe neurological compromise. About 75% of children are treated with a course of chronic dialysis before renal transplantation, but unless there is a need for specific pretransplant preparation, there is no advantage to pretransplant dialysis. For adults, preemptive renal transplantation has a survival advantage, whereas in children, although advantage is harder to show, there is no detriment.
Recipient Age at Transplantation
Kidney transplantation before 6 months of age or in a recipient who weighs less than 6 kg is very unusual. Since 1987, NAPRTCS has recorded approximately 560 transplants performed in children younger than 12 months, around 5.3% of the total. The yearly number has dropped in more recent years. Because infants and adolescents have different risk factors for both patient and graft survival, children frequently have been grouped into five age categories: 0 to 1 year, 2 to 5 years, 6 to 12 years, 13 to 17 years, and 18 to 21 years of age. In 1987 25% of all pediatric transplants were performed in children 0 to 5 years of age, whereas by 2010 the same age group accounted for 20%. The decreased number of transplants in this group is likely due to greater surgical challenges in these small recipients, combined with the development of better dialysis for infants. However, excellent results have been obtained in very young patients in some individual centers. The concept of a heightened immune response in young recipients is controversial. Thus the unique problems associated with transplantation in young recipients may be related to infections, technical issues, and differences in pharmacokinetics rather than to their immune response.
There has been a substantial change in long-term renal allograft outcome for children during the past three decades. Infants have flipped from poor long-term allograft survival to the best long-term survival. Conversely, however, adolescents were subsequently noted to have a higher rate of late acute rejections ; infants may have a lower rate of acute rejection than older children. An important analysis of the United Network for Organ Sharing (UNOS) data demonstrated that in the mid-1990s, short-term pediatric renal transplant survival rates became comparable to those in adults. The most recent comprehensive registry reviews have clearly demonstrated a dramatic reversal in outcomes. Improvements in surgical technique, donor selection, immunosuppression practices, the enhanced experience of specialized pediatric transplant teams, and the development of multicenter research consortia have all led to marked improvements in patient and kidney graft survival for infants and young children.
Currently, pediatric recipients have 5-year allograft survival rates of 86.5% if from an LD and 83.2% if from a DD, which is comparable to rates seen in adults. Unfortunately, this excellent outcome is not seen in adolescents, whose 5-year graft survivals are less than 80% and whose 10-year graft survival is only 50%, worse than all other age groups except the most elderly. The graft failure risk dramatically increases between the ages of 11 and 24.
Before a child can undergo renal transplantation, the problems caused by CKD must be addressed and optimized if possible. In those cases where ESRD is due to urological abnormalities, corrective reconstructive surgery should be undertaken, especially to the lower urinary tract, before transplantation. Two of the major consequences of CKD are anemia and growth retardation, both of which should be addressed before transplantation. A recent report of final adult height in pediatric renal transplant recipients suggests that the current improvement in final adult height posttransplantation is more related to improving height deficits before transplantation than to any net gains achieved after transplantation. Uremia also leads to wasting and malnutrition in the child, and this can compromise the success of the procedure. For example, prophylactic native nephrectomy and reversal of protein wasting and malnutrition improve the outcome of transplantation in children with congenital nephrotic syndrome. Careful preparation is particularly important in children undergoing preemptive transplants. Because live viral vaccines are generally not indicated in chronically immunosuppressed patients, children should receive all appropriate vaccines pretransplantation. Whereas guidelines exist for the evaluation of the adult transplant recipient, there are no similar published reports for pediatric patients.
Children with the developmental diagnoses described in Table 43.1 require a thorough urological evaluation before transplantation, and they frequently require pretransplant reconstructive urological surgery. Lower urinary tract abnormalities are present in as many as 25% of pediatric kidney transplant recipients. For all such patients, a history of voiding pattern before development of renal failure is most helpful. In pretransplant testing, urinary flow rate should be at least 15 mL per second, the postvoid residual volume should be less than 30 mL, and urinary bladder pressures should not exceed 40 cm H 2 O. Further investigations would consist of urethrocystoscopy in patients suspected of a urethral stricture, and a voiding cystometrogram is essential for complete assessment of bladder function. This provides information about bladder capacity, pressure rise, and the efficiency of voiding. Still more information can be obtained by combining the urodynamic studies with radioisotope imaging. Routine voiding cystourethrogram is not indicated in older children with no symptoms related to the urinary tract.
A bladder with a very small capacity may not be adequate for a functioning transplant. Occasionally a small-capacity bladder may be seen in patients with prolonged oligoanuria. However, if the bladder is distensible and the bladder wall compliant, such a bladder may be used safely for kidney transplantation. When a bladder fails to empty completely, infection and obstruction are potential complications that may shorten graft survival. Clean intermittent self-catheterization, which is widely used in urological practice, can be safely used posttransplantation in patients where the primary abnormality is an inefficient and uncoordinated detrusor function.
Most pediatric patients have a urinary bladder that will adapt to the new kidney. Although the bladder may not appear to have the capacity, especially in patients on long-term dialysis before transplantation, it will most often distend with usage. However, in patients with a truly low-capacity or high-pressure bladder, augmentation may be necessary before transplantation. The goal of modern reconstructive pediatric urology is to have a competent low-pressure urinary reservoir that can be emptied by voiding or at least by intermittent catheterization. Augmentation cystoplasty consists of adding bowel or gastric wall to the bladder, whereas substitution cystoplasty is performed when most of the bladder is excised and replaced with bowel. Gastric remnants have been popular for augmentation; however, they do tend to cause excessive loss of acid in the urine, leading to discomfort and metabolic alkalosis. These augments typically are performed pre–kidney transplant. In patients in whom augmentation has been performed, long-term antibiotic therapy and intermittent catheterization may have to be carried out to prevent urine stasis and infection. In general, the incidence of urinary tract infection (UTI) and other complications is higher in these recipients; their graft survival may also be slightly worse than in pediatric recipients without urological abnormalities.
If native kidneys in children with ESRD are causing hypertension, chronic infections, or excess losses of protein, urine, or other substances, there should be serious consideration for nephrectomy before or at the time of transplantation. About 25% of children have native nephrectomies before transplantation.
The selection of the appropriate donor is an integral part of the transplantation procedure and may be a limiting factor in the long-term outcome of kidney transplantation for any individual child. The use of LDs has generally been much more common in pediatric kidney transplantation than in adults. In general, the choice of an LD is a good one because, on average, graft survival can be twice as long when an LD is used compared with a DD. There are limitations to the use of LDs, however, such as donor suitability, blood group incompatibility, and age; thus not every child may have a suitable LD. When DDs are used for children, careful attention should be paid to using low-risk donors because the mortality risk for children after kidney transplantation is low and children are expected to require the grafts for long periods of time.
The Transplantation Procedure
Technical Issues in Transplantation
The operative technique differs based on the weight of the child. For children less than 15 kg, the transplant is performed through a midline incision, and the large abdominal vessels are used. After reflection of the right colon, the aorta and the inferior vena cava are exposed. The aorta is mobilized from above the inferior mesenteric artery to the external iliac artery on the right side. After the lumbar branches are ligated and divided, the iliac arteries and the inferior mesenteric are encircled. Next the inferior vena cava is mobilized from the left renal vein to the iliac veins. After the lumbar veins are ligated, the iliac veins are encircled. The donor renal vein is anastomosed to the recipient vena cava in an end-to-side technique. The donor renal artery is then anastomosed to the recipient aorta in an end-to-side fashion. Careful attention must be paid to the recipient’s hemodynamic response upon clamping and unclamping of the major vessels, and it is desirable to maintain a central venous pressure of 15 to 18 cm H 2 O before unclamping. The perfusion of the transplanted kidney may be slow because a large adult kidney will take up a significant portion of the normal pediatric blood volume. Hemodynamic studies suggest that the cardiac output of infants must double to perfuse the adult donor kidney adequately. Thus volume replacement is critical when the kidney is large relative to the infant’s body ( Fig. 43.1 ). The ureteral anastomosis is performed by implanting the donor’s ureter into the recipient’s bladder, most commonly these days via a nonrefluxing extravesical (Lich-Grégoire) approach rather than an intravesical approach (Politano-Leadbetter procedure) because it is faster, a separate cystotomy is not required, and less ureteral length is necessary, thus assuring a distal ureteral blood supply.
The transplantation technique used in children with a body weight greater than 15 kg is similar to that employed in adults. Unlike the transperitoneal approach necessary in younger children, this transplant is extraperitoneal, with the renal vein anastomosed to the common iliac or the external iliac vein. The arterial anastomosis can be to either the common iliac or internal iliac artery. The ureterovesicular anastomosis is performed using the techniques described earlier.
Evaluation of Graft Dysfunction
At the completion of the vascular anastomosis and release of the vascular clamps, immediate function of the transplanted kidney is demonstrated by the production of urine. Various causes, however, may prevent initial function, and evaluation of immediate nonfunction and the differential diagnosis of this condition are critical components of the transplant physician’s role (see Chapter 36 ).
Delayed Graft Function
A well-functioning kidney graft should lead to normal renal function within 2 to 3 days. The lack of attainment of normal renal function, as would be demonstrated by a fall of the serum creatinine to normal levels, is termed delayed graft function (DGF). There is no consensus concerning the definition of DGF. In some settings, DGF is used only to distinguish recipients who require dialysis after transplantation, but that is a very stringent definition. Acute tubular necrosis (ATN) represents the most frequent cause of immediate graft nonfunction in children. Current data from the NAPRTCS show that ATN was observed in 4.8% of LD and in 14.7% of DD index transplants (Karen Martz, personal communication). Because the NAPRTCS definition for ATN is the stringent “requiring the use of dialysis in the first posttransplant week,” these figures probably underrepresent the actual incidence of ATN. The risk for early ATN is related to factors such as prior transplants, prolonged cold ischemia, absence of prophylactic antibody therapy, and the use of more than five pretransplant blood transfusions. The diagnosis is confirmed in most cases by Doppler sonography or the use of radionuclide scan ( Fig. 43.2 ). If recovery of graft function is delayed, however, a transplant biopsy may be necessary, because other diagnostic tests cannot distinguish between ATN and rejection or recurrence of primary disease. Importantly, early acute rejection can mimic ATN or coexist with it. The presence of ATN does not auger well for the transplant, because the acute rejection rate jumps from ∼20% to 30% in LD and 40% in DD transplants to children. Long term, there is a 15% to 20% drop in graft survival in children if ATN occurs immediately posttransplant.
Importantly, although the incidence of DGF is increased when a donation after cardiac death (DCD) donor is used, the detrimental effect of DGF on long-term outcomes in this setting does not appear to be as severe as when it occurs after living donation or after transplantation from brain-dead DDs.
Graft thrombosis is an almost unique complication of Pediatric Transplantation. Although usually a major cause of immediate graft nonfunction, it can be seen later on in the course and has been recorded to occur as late as 15 days posttransplantation after initial engraftment and function. Graft thrombosis has been the third most common cause of graft failure in pediatric renal transplantation and may rise to second as acute rejection rates continue to fall. The critical nature of this complication can be appreciated from the fact that it accounts for ∼10% of graft failure in index transplantation and 12% in repeat transplants in the NAPRTCS registry. A dreaded event, this condition is irreversible in most cases and necessitates removal of the graft. Graft thrombosis should be suspected in cases where there has been immediate function followed by the development of oligoanuria. The diagnosis is established by sonography or radionuclide scan using diethylenetriamine pentaacetic acid (DTPA) or MAG3, which reveals a photopenic defect with no uptake by the transplant kidney ( Fig. 43.3 ).
Because the outcome of graft thrombosis is uniformly dismal, numerous studies have been conducted in an attempt to understand and anticipate this complication. The etiology of graft thrombosis is multifactorial, but it is more commonly seen in young recipients. In a special study of 2060 LD and 2334 DD kidneys, the NAPRTCS has shown that a history of prior transplantation increases the risk, whereas increasing recipient age has a protective effect for LD kidneys. The prophylactic use of antilymphocyte antibody also decreases the risk, and this may be particularly true for the monoclonal interleukin-2 receptor (IL-2r) antibodies. For DD kidneys, a cold ischemia time longer than 24 hours increases the risk for thrombosis. The use of antibody induction therapy, the use of donors older than 5 years of age, and increasing recipient age were factors that decreased the risk for thrombosis. One study showed that centers that performed fewer infant transplants had higher rates of graft thrombosis, and other studies suggested that pretransplant use of peritoneal dialysis increased the risk for thrombosis. Some centers routinely administer anticoagulants to pediatric recipients at high risk for graft thrombosis, but no clinical studies of their effectiveness have been performed, and their use is not without complications.
Obstruction, Urinary Leak, and Urological Complications
An uncommon but correctable cause of immediate graft dysfunction is obstruction of the urinary flow, which presents as decreasing urine output and the development of hydronephrosis. An ultrasound or radionuclide scan with a furosemide washout enables the clinician to establish this diagnosis. Obstruction can be due to kinking of the ureter, to edema or blockage of the implantation site of the ureter, or to development of a lymphocele. A more ominous cause of immediate nonfunction is the rare case of urinary leak due to disintegration of the distal ureter or rupture of the bladder. This condition is extremely painful due to the extravasation of urine into the pelvis or peritoneal cavity and is established by radionuclide scan ( Fig. 43.4 ). The appearance of the tracer in the peritoneal cavity or in the scrotal, vulvar, or inguinal area clinches the diagnosis, and immediate surgical correction is necessary.
Between 80% and 90% of pediatric kidney transplant recipients currently receive antibody-based induction therapy after kidney transplantation, with the majority of those receiving T-cell depleting agents. In addition, most children receive triple maintenance immunosuppression with tacrolimus, mycophenolate mofetil (MMF), and steroids. As shown in the NAPRTCS annual report, the “typical” immunosuppression protocols have changed frequently over the past two decades ( Fig. 43.5 ). However, it also appears as though children who begin treatment under one combination stay on that regimen. Several recent multicenter research efforts have been directed toward an attempt to decrease the number of types of chronic immunosuppression, with corticosteroids and calcineurin inhibitors (CNIs) being the most common medications targeted for removal. Several multicenter trials have reported success in avoiding or withdrawing corticosteroids, although some of these have had substantial adverse effects. There have also been reports of avoidance of CNI in children, a move designed to prevent nephrotoxicity. At least one of these trials resulted in excellent long-term graft function but had a high rate of early acute rejections. In general, children metabolize immunosuppressive drugs faster than adults. Thus data show that young children often need cyclosporine dosing three times a day or sirolimus twice a day, versus the standard dosing used in adults. Body surface area dosing of drugs may be more accurate than per-kilogram dosing in young children.
In the absence of tolerance, the renal allograft is destined for loss by some form of rejection. Rejections are classified as hyperacute (occurring immediately upon grafting), accelerated acute (occurring within the first week after transplantation), acute (generally occurring within the first year of transplantation), late acute (occurring after the first year), and chronic, for which the time sequence is difficult to establish, because it may occur as early as 3 months but generally occurs years later in the course of the transplant. The original disease that caused the native kidneys to fail may also affect the transplanted kidney.
Hyperacute rejection is the result of specific recurrent antidonor antibodies against human leukocyte antigen (HLA), ABO, or other antigens. Irreversible rapid destruction of the graft occurs. Histologically there is glomerular thrombosis, fibrinoid necrosis, and polymorphonuclear leukocyte infiltration. In the early years of transplantation, when the HLA-matching techniques were not well developed, hyperacute rejection was more common. As in adults, hyperacute rejection has become exceedingly rare in children. The only treatment is surgical removal of the allograft. Graft failure from hyperacute rejection is reported in only 0.7% of all index or subsequent transplants in the last NAPRTCS report.
Information regarding the incidence and outcome of acute rejection in pediatric renal transplantation is available from the NAPRTCS data. Because NAPRTCS receives data from multiple centers that use different diagnostic and treatment protocols, the definition of a rejection episode is based upon the circumstance of a patient having been treated with antirejection therapy, although biopsy confirmation is becoming more common. A remarkable decrease in the incidence of acute rejection has occurred over the past 30 years ( Table 43.2 ). In a study of two cohorts of pediatric renal transplant recipients (1469 in 1987–89; 1189 in 1997–99), the rejection ratios dropped from 1.6 to 0.7 per patient. Sixty percent of the latter group were rejection-free compared with 29% of the former, and 1-year graft survival was 94% compared with 80%. Historically, more than half of the patients experienced a rejection in the first posttransplant weeks; now the great majority of patients experience a rejection-free first year. In the most recent cohorts, the 1-year acute rejection rates are 8.6% for LD transplants and 16.6% for DD transplants.
|Transplant Year||Living Donor||Deceased Donor|
Risk factors for rejection after DD transplantation include the absence of prophylactic depleting antibody induction therapy, donor age younger than 5 years, African American race, and no antigen D–related (DR) matches. Risk factors for rejection after LD transplantation are the absence of lymphocyte-depleting antibody induction and one or two DR mismatches, African American race, and ATN. In an earlier study, the NAPRTCS noted that when reviewed by age groupings, rejection ratios, time to first rejection, and the mean number of rejection episodes were not different; however, for the initial rejection episode, recipients younger than 6 years of age had significantly increased irreversible rejections leading to graft loss. On the other hand, data from surveillance transplant biopsies suggest equivalent rejection responses in all groups. Most recent Scientific Registry of Transplant Recipients (SRTR) data demonstrated that infants and young children now have the best outcomes of all age groups. Thus either the proposed heightened immune response has been overcome by improved immunosuppression or the cause of previously poor outcome was related to other factors.
Diagnosis of Acute Rejection
Rejection is suspected when there is decreasing urinary outflow and a rising serum creatinine. In the past, classical signs of acute rejection included fever and graft tenderness. Under CNI and prophylactic antibody therapy, however, these signs are rarely seen; thus early evidence of graft dysfunction should initiate concern. The differential diagnosis consists of ureteral obstruction, renal vascular compromise from stenosis, urinary leak, and an infectious process. When rejection is suspected, a urinalysis and urine culture should be performed to assess the possibility of infection. The urinalysis is also helpful if it suggests intragraft inflammation or immune response as evidenced by proteinuria and the presence of leukocytes and other cells in the sediment. Blood or urinary cytokine/gene expression analyses may also be useful for diagnosing rejection, although they are not used on a routine clinical basis. Examination of the urine sediment may be useful in detecting reasons for graft dysfunction, such as infection or recurrence of the primary kidney disease. An ultrasound is performed to rule out anatomical obstruction. Obstruction can be the result of a lymphocele, hematoma or, rarely, an abscess. The ultrasound can also provide information about intragraft blood flow and pressure. A radionuclide renal scan, using a tracer such as 99m Tc-MAG3, is a very helpful tool in establishing some diagnoses (see Figs. 43.3 through 43.5 ). Rejection is suggested by rapid uptake of the tracer by the kidney, but with a delayed excretion. Unfortunately, radionuclide scans cannot distinguish among various causes of intragraft dysfunction, such as rejection, cyclosporine toxicity, and ATN. Thus a definitive diagnosis of rejection requires a transplant biopsy.
Pediatric Renal Transplant Biopsy
The renal transplant biopsy procedure is very easy and safe when conscious sedation and ultrasound guidance are used. Data evaluating renal transplant biopsies, including some in intraperitoneal kidneys and many performed during the first week posttransplantation, have demonstrated a very low risk for major complications. A major factor in reducing postbiopsy bleeding is the use of an automated biopsy device using a small (18 gauge) rather than a standard (15 gauge) needle. Biopsies should be performed in pediatric renal transplant recipients whenever the diagnosis of rejection is in doubt.
Treatment of Acute Rejection
The standard initial treatment of an episode of acute rejection is still intravenous methylprednisolone in a single daily dose of 10 to 20 mg/kg (maximum dose: 0.5 g) for three consecutive days. Most Banff grade I and II rejections will respond to steroid therapy. Steroid-resistant rejection episodes are treated with lymphocyte-depleting antibody therapy, such as the polyclonal rabbit antithymocyte globulin Thymoglobulin. Thymoglobulin is now given in a dose of 1.0 to 1.5 mg/kg/dose for a total of 5 to 14 days, generally not exceeding 7.5 mg/kg in more recent cohorts. It may be advisable to monitor CD3 + cells during treatment and to restrict the frequency of dosing to days when the count is greater than 20 cells/mm . All antibodies have several side effects. Precaution against the potential anaphylactic reaction related to polyclonal antibodies consists of using 500 mg of methylprednisone with the infusion of the antibody and administering an antihistamine such as diphenhydramine (Benadryl) 30 minutes to an hour before drug administration.
Reversibility of Acute Rejection
From the recent NAPRTCS data it was observed that among LD kidneys, 52% of rejection episodes were completely reversed, 44% were partially reversed, and 5% ended in graft failure. Similar figures for DD kidneys are 45%, 48%, and 7%, respectively. When stratified by age, young transplant recipients have irreversible rejection episodes more frequently. Ten percent of acute rejections among infants receiving an LD kidney ended in graft failure, compared with 4% for older children. For DD kidneys the rate of graft failure in infants was 15%, compared with 7% for older children. Molecular or genomic characterization of rejection biopsies, many derived from pediatric cohorts, may become more helpful in describing different types of acute rejection.
In those patients for whom neither steroids nor antibody therapy has successfully reversed a rejection episode, conversion to an alternative CNI or to other immunosuppressants may be warranted. There have been no controlled studies in children to document reversal of rejection with conversion to tacrolimus; however, anecdotal reports do suggest that in some cases conversion helps stabilize graft function.
Chronic Allograft Dysfunction
The gradation from acute to chronic rejection is gradual; however, many biopsies may show features of both, and some characteristic vascular changes of chronic rejection may be seen early. The clinical picture is that of gradually declining renal function together with varying degrees of proteinuria and hypertension. The clinical condition may be referred to as transplant glomerulopathy, chronic rejection, chronic allograft dysfunction (CAD), chronic allograft nephropathy (CAN), or interstitial fibrosis and tubular atrophy (IFTA). The succession of names reflects lack of clarity of the etiology, clinical course, or treatment of this disorder. Nonetheless, this process, which will be referred to as CAD in this chapter, is the leading cause of graft loss after kidney transplantation in children.
An ongoing controversy exists as to whether the changes seen in chronic rejection are immune mediated, secondary responses to infection, ischemic in nature, or nonimmunological injury due to hyperfiltration. Data in children have shown clearly that acute rejection is a predictor of chronic rejection. In a study of 1699 LD and 1795 DD recipients, NAPRTCS noted that acute rejection was a relative risk (RR) factor for chronic rejection (RR = 3.1) and that multiple acute rejections increased the RR to 4.3. Late acute rejections are also clinical correlates of chronic rejection. Even if acute rejection is the most critical element in the genesis of chronic rejection, other immune mechanisms may mediate its progression, such as antibodies directed against the donor, major histocompatibility complex class I–related chain A (MICA), endothelial cells, and B lymphoblasts. Gene expression profiles in graft biopsies of patients with established CAD demonstrate upregulation of profibrotic and growth factors, and now such profiles may be able to predict later CAD.
Symptomatic therapy is currently the only available method of dealing with CAD. Hypertension should be controlled, and the proteinuria may occasionally respond to angiotensin-converting enzyme (ACE) inhibitors; however, renal function will generally continue to decline. In children, CAD produces an additional burden because decreased renal function will result in deceleration of growth. It is in this context that prevention of chronic rejection by early aggressive therapy in patients who have had an episode of acute rejection may be rewarding. Because currently available immunosuppressive medications have been unsuccessful in preventing or slowing the progression of chronic rejection , the use of regimens without steroids or immunosuppressives other than those currently approved may be reasonable, such as the use of costimulation blockade rather than nephrotoxic CNIs. Although some programs have concluded that these techniques might be beneficial after CAN is established, there may be a point at which substitution of nonnephrotoxic agents is not helpful. The presence of heavy proteinuria in recipients with CAD may also predict lack of benefit of changing chronic immunosuppression.
Recurrent Kidney Disease
Some diseases will recur in a transplanted kidney, and the recurrent disease may lead to loss of the graft, as it had done to the native kidneys previously. Recurrence of the original disease is the cause of 7% of all graft losses, and it is the cause of up to 9.5% of graft losses in subsequent transplants. Thus recurrence is one of the top four causes of all graft losses to children, which is unlike graft losses to adults. The 5-year LD graft survival for children with FSGS is 71%, and for children with glomerulonephritis it is 77%, in contrast to all other causes of ESRD, in which 5-year graft survival is greater than 83%. Several other pediatric diseases also recur posttransplant. In particular, atypical hemolytic uremic syndrome (HUS) from genetic deficiencies of complement inhibitors can recur in 20% to 80% and is the attributable cause of graft loss in 10% to 80%, especially for factor H mutations. Membranoproliferative glomerulonephritis (MPGN) type II, also related to complement cascade, has very high recurrence rates of 66% to 100% and attributable graft loss rates of 25% to 60%. Hyperoxaluria or oxalosis, a genetic disease, recurs in 80% to 100% and is the attributable cause for graft loss in 90% to 100%. More details are described later.
Focal Segmental Glomerulosclerosis
FSGS is the most common cause of steroid-resistant nephrotic syndrome leading to ESRD and is the most common acquired cause of ESRD in children. Reports of recurrence of FSGS vary from 15% to 50%, and about 50% of the recurrences lead to graft loss. FSGS is a pathological diagnosis and represents the appearance of a large number of diseases that might be due to immunological, genetic, or other causes. The genetic diseases do not seem to recur in a graft. Risk factors for recurrence include early onset of nephrotic syndrome, rapid progression to ESRD (<3 years), resistance to treatment, Caucasian or Asian race, recurrence in a previous transplant, and possible presence of a circulating glomerular permeability factor. Recurrence can occur immediately after transplantation and result in massive proteinuria, ATN, and even graft failure related to small vessel thrombosis. Typical FSGS lesions on pathological examination, other than foot process fusion, may not appear early in the course of recurrence but may follow early thereafter. In general, children with active nephrotic syndrome are not candidates for preemptive transplant because of the heavy proteinuria and consequent risk for graft thrombosis and delayed diagnosis of recurrence. Many programs will perform native nephrectomy and will maintain the children on chronic dialysis for some period of time, certainly to improve nutritional status and to normalize the serum albumin. There is no benefit to LD transplantation in children with recurrent FSGS; although graft loss due to rejection is lower in recipients of LD transplants, graft loss due to recurrence is higher, leading to equivalent graft survivals in LD and DD transplants. Whether this is the result of a higher frequency of recurrence in LD recipients, a more aggressive course in those recipients, or simply a higher rate of rejection in the DD recipients is not known. Plasmapheresis is often used prophylactically before transplantation or immediately after it to attempt to prevent or treat recurrence of FSGS, and some programs report complete remission in up to 60% treated in that manner. Rituximab has also been used to treat recurrent FSGS in children, with mixed results.
Hemolytic Uremic Syndrome
HUS in children is most commonly caused by enteropathic bacteria and Shiga toxin, and this version of the disease typically does not cause ESRD or recurrence in a kidney transplant. On the other hand, children with atypical or non-Shiga toxin-associated HUS have a much higher incidence of progression to ESRD and recurrence of the disease after transplantation. In patients with factors H or I or with B mutations, the recurrence rate appears to be high, and transplantation may be deferred. Eculizumab therapy at transplant can reduce or treat recurrence.
Membranoproliferative Glomerulonephritis, Types I and II
Both forms of MPGN can recur in transplants, with variable frequency from 30% to 60%. Type II seems to be more severe, and neither form seems to be treatable after recurrence.
Oxalosis, Methylmalonic Acidemia, and Metabolic Diseases
Primary oxalosis recurs almost immediately and universally after kidney transplantation and was once considered a contraindication to kidney transplantation. However, treatment with intensive pretransplant and posttransplant plasmapheresis to lower the body burden of oxalate, along with the use of combined kidney-liver transplantation, has led to substantially better outcomes. If liver transplantation is being considered, however, careful consideration must be paid to determining whether the child has a variant that might be responsive to lifelong treatment with pyridoxine rather than liver transplantation. Methylmalonic acidemia may be partially ameliorated by kidney transplantation, but full treatment may require liver transplantation in select recipients. Certain inherited diseases, including insulin-dependent diabetes mellitus and sickle cell disease, may recur in a kidney transplant, but this almost universally happens during adulthood, many years after the primary transplant in a child.
Other Autoimmune Diseases
Immunoglobulin A (IgA) nephropathy, Henoch-Schönlein purpura, lupus nephritis, and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis may recur after kidney transplantation in children, but these recurrences may be minimally apparent and less frequently lead to graft loss. Surprisingly, lupus nephritis does not recur to any great extent after renal transplantation. Patients with lupus have similar outcomes compared with other patients, except for a slight increase in mortality, an increase in incidence of recurrent rejections, and a slight tendency to graft failure in those patients receiving DD grafts after peritoneal dialysis.
ESRD is typically the earliest organ failure in children with cystinosis and often accounted for the bulk of deaths from this disorder. However, the use of kidney transplantation and cystine-depleting therapy with cysteamine has extended their life expectancy to the fifth decade. Although cystine may accumulate in the interstitium of renal grafts, it does not cause graft failure. However, the unremitting accumulation of cystine results in substantial nonrenal morbidity and mortality.